Transcript HERE - The Family Doctor Association

Top Tips for GPs
Christopher Dowrick
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Quiz
Top Tips
Case studies
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Women
People with higher socioeconomic status
Patients from larger families
People who have had early life difficulties
People who have experienced stressful life
events
Women
 People with higher socioeconomic status
 Patients from larger families
 People who have had early life difficulties
 People who have experienced stressful life
events
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5%
25%
50%
85%
5%
 25%
 50%
 85?
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True
False
True
 False
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Taking the patient’s symptoms seriously
Focusing on diagnosis rather than function
Using the patient’s language to offer tangible
explanations
Safety-netting
Insisting on psychological explanations
Taking the patient’s symptoms seriously
 Focusing on diagnosis rather than function
 Using the patient’s language to offer tangible
explanations
 Safety-netting
 Insisting on psychological explanations
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CBT is helpful in somatisation disorder
Amitriptyline improves symptoms in
fibromyalgia
10% of patients attending outpatients have
MUS
Reattribution is an effective intervention for
MUS
Exercise is an effective treatment in IBS
CBT is helpful in somatisation disorder
 Amitriptyline improves symptoms in
fibromyalgia
 10% of patients attending outpatients have
MUS
 Reattribution is an effective intervention for
MUS
 Exercise is an effective treatment in IBS
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People want to be
taken seriously: show
your patient you
believe them.
Concentrate on
helping your patient
to manage symptoms
and improve function.
Continuity of care can
have a positive
impact.
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MUS are commonly presented in primary care
MUS can be understood from different
perspectives
◦ Functional somatic problems
 Fibromyalgia, IBS, CFS/ME etc.
◦ Psychiatric disorders
 Somatoform or somatisation disorders, bodily distress
syndrome
◦ Dysfunctional doctor-patient relationships
◦ Entrenched cultural beliefs
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PHQ-15 may be
helpful
Many presentations
are self-limiting
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Avoid strategies that
exacerbate or
perpetuate MUS
◦ Dismissing
◦ Distancing
◦ Excessive
investigation or
referral
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Patient (P): ‘The other thing doctor, my
stomach is very extended at the moment …
I’m finding now everything I eat, it used to be
high fat foods like chips or you know a curry
or something like that, but now it’s
everything I eat, my stomach is really swollen.
I notice certain clothes I just can’t wear now,
you know at certain times because my
stomach’s really …’
Dr: ‘Just get bloated do you?’
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GPs most likely to criticise patients who
seek emotional support
◦ Criticism in 88 (27%) consultations
◦ Patient seeks
 Explanation:
 Management:
 Support:
1.09
1.15
1.38
(0.76, 1.56)
(0.94, 1.42)
(1.08, 1.77)
 Salmon et al, Psychosom Med 2006
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Somatic outcomes directly associated with
◦ length of consultation
 t 2.742, p 0.007
◦ elaboration
 t 1.990, p 0.047
◦ NB not associated with
 Patients’ reference to physical disease
 Patients’ proposal for somatic management
 Salmon et al, Psychosom Med 2007
70
%
60
50
40
Doctors
Patients
30
20
10
0
Prescription
Investigation
Referral
Z=12.19, P<0.001
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Successful
consultations
include
◦ alliance
◦ blame-reduction
◦ convincing
explanations
◦ encouraging patients’
psychosocial talk
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Somatic outcomes
less likely if GPs’
facilitate patients’
psychosocial talk
 P=0.001
◦ not if GPs offer
psychosocial
explanations
 P=0.926
 Salmon et al,
Psychosom Med
2007
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Physical
Psycho-social
Pharmacological
Practical
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Physical
◦ Focused examination
◦ Minimise investigations
 Expect negative findings
◦ Reduce unnecessary drugs
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Psycho-social
Acknowledge reality of symptoms
Provide convincing explanations
Focus on function
Be realistic about areas of agreement and
disagreement
◦ Consider specialist referral
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Dr: ‘Is that sore there?’
P: ‘Yes.’
Dr: ‘Yes. It’s the big muscle group isn’t it? It feels
quite tense on this side as well actually. Think
that’s with all the tension and stress? How are
things working
out?’
P: ‘Finding it a bit difficult ... because sort of
people go through the motions you know, of
being very busy and getting paid for doing, you
know, passing pieces of paper around. I was
going spare on Friday.’
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Dr: ‘The only thing that fits is, it’s the sort of pain you get
with shingles because it comes around in that pattern.’
P: ‘Yes, yes.’
Dr: ‘And that’s sometimes irritation of the nerve endings.’
P: ‘That’s what somebody else, me Nan says, “It could
be your nerves”.’
Dr: ‘I don’t mean your emotional nerves, your actual
physical nerves that come round your body — but it
could be made worse by stress and things like that.’
P: ‘I mean I’m obviously one of them people that are
highly strung anyway, I know that. I’m not, I’m not you
know, come day go day, like [a] laid back person, I’m
quite like you. Know everything’s got to be done at that
day, at that time.’
Dr: ‘Have you had any sort of relaxation to see if that
would help your pain?’
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[Not function of symptoms]
Impairment or disability as a result of
symptoms
◦ ‘What does [x] stop you doing?’
◦ ‘What can we do to overcome this?’
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Pharmacological
◦ Treatment aimed at symptoms
 e.g. pain
◦ Consider psychoactive medication
 If patient agrees
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Practical
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Regular appointments
With same doctor
Relative as therapeutic ally
Support and supervision
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Palpitations
No chest pain or
SOB
Ix normal including
thyroid and 24hr
ECG
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Connect
Summarise
Hand over
Safety net
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Psychosocial links
? PHQ-9, GAD-7
If symptoms persist
◦ Somatisation disorder?
◦ Consider CBT
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Loose stools
Peri-umbilical pain
No blood/mucus PR
Weight stable
No meds
Father died ca
prostate
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Examination
◦ Incl PR
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Bloods
◦ CRP, FBC, ESR, coeliac
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Px
◦ Loperamide
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Consider stressors
Empathy
Red flags
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Persistent
generalised body
pain
TATT
No meds
No joint pains, good
RoM
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Bloods
◦ Predict normal results
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Fibromyalgia
◦ Explain diagnosis
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Symptom control
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Breathlessness
Chronic low back
pain
IBS
Complaint against
‘incompetent’
colleague
Requesting referral
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Physical examination
Defer referral
Extended appointment
Regular appointments
with you
? Liaison
psychiatry/GPsSI
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stomach pain
‘Oh no, it’s starting
again’
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headache
mole on arm
throbbing leg
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What do these
symptoms stop you
doing?
◦ ‘taking my grandson
to school’
◦ ‘painting’
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People want to be
taken seriously: show
your patient you
believe them.
Concentrate on
helping your patient
to manage symptoms
and improve function.
Continuity of care can
have a positive
impact.

Guidance for health professionals on MUS
◦ RCGP/RCPsych 2014
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Managing MUS in primary care
◦ Doctors.net.uk